Women with diabetes are 2-4 times more likely to have a baby with an abnormality and five times as likely to experience a stillbirth as women without diabetes. Effective preconception care (PCC), improves outcomes, but nationally only a third for pregnant women with diabetes access this care. To address this, Derby hospitals piloted PROCEED, a user-centred model for PCC that integrates care vertically across specialities, and horizontally across Primary and Secondary Care. After 12 months, median waiting times reduced from 13 to five weeks and the ‘did-not-attend’ rate from 18 to five per cent. The PCC rate increased to 70 per cent and the stillbirth rate fell from 6 per cent in 2009/10 to 0 per cent. Women valued the flexibility and choice, describing the service as ‘first-class’, while savings to date are £61,000.
Our challenge was to reduce the number of pregnancies of women with diabetes resulting in stillbirth, infant mortality and congenital defects.
Pregnancy poses additional risks for women with diabetes and their babies. Babies of women with diabetes are:
The local scenario
- Five times as likely to be stillborn
- Three times as likely to die in their first months of life
- Two to four times as likely to have a major congenital anomaly.
The local diabetes in pregnancy service covers Derby and Southern Derbyshire and serves a population of 600,000. The maternity unit handles over 6,000 deliveries a year – 35-50 of cases the mother has diabetes before pregnancy.
Until recently, in common with other centres, Derby Hospitals NHS Foundation Trust provided a multidisciplinary consultant-led Secondary Care preconception service based in an antenatal clinic setting. In 2002/3 local PPC rates and pregnancy outcomes were similar to national data. In 2006, the Trust raised awareness of the importance of PCC among women with diabetes and the professionals involved in their care. As a result of this, the PCC rate rose from 32 per cent in 2002-03 to 68 per cent in 2006-07, and the congenital abnormality rate fell from 11 per cent to 2 per cent and no stillbirths occurred.
From 2009, service capacity reduced as a result of the reconfiguration of diabetes services. Meanwhile service demand remained stable resulting in increased waiting times and an increasing numbers of women becoming pregnant while waiting to be seen. PCC rates started to fall towards baseline levels, and adverse outcomes increased; in particular, the stillbirth rate increased to 6 per cent.
There was considerable variation in the care received ranging from no care or single professional consultations to full multidisciplinary care. Certain populations were not accessing care, particularly teenagers and women from ethnic minority communities from poor socio-economic backgrounds. Furthermore, users reported difficulties accessing a hospital-based clinic and many described attending an antenatal clinic setting as stressful, particularly if they had experienced a miscarriage or were undergoing fertility treatment, contributing to the fact that 18 per cent of appointments were not attended.
Clearly there was the need to redesign the preconception care service to improve capacity, and provide an equitable service that met user needs more effectively. Derby Hospitals NHS Foundation Trust considered whether it could work with specialist colleagues who are now in Primary Care and the organisations they worked for to work as a ‘team without walls’. Derby Hospitals NHS Foundation Trust was fortunate to receive 12 months funding from The Health Foundation’s SHINE programme to pilot PROCEED (Preconception Care in Diabetes in Derby/Derbyshire) the first integrated preconception service, that integrates care not just vertically across diabetes and obstetrics specialties but for the first time horizontally across the boundaries of primary and secondary care. We started the project in April 2011 and report our 12-month data.
Derby Hospitals NHS Foundation Trust aims were to improve service quality, and save money by working in partnership with organisations across the boundaries of Primary and Secondary care through:
1. Improving effectiveness and timeliness by
- Redesign the service considering national guidance
- Raise awareness of the need for preconception care among all professionals in contact with women with diabetes as well as women with diabetes to increase the number of referrals into the service
- Increase service capacity by integrating the service across traditional boundaries of Primary and Secondary Care
- Review the adherence to management plans and targets to maximise the clinical quality of the service
- Ensure the lean delivery of the service to reduce waiting times and the total time spent in the service thus reducing the number of women entering pregnancy with suboptimal preparation.
2. Providing a person centred service and equity of care by
- Involve users in the service redesign
- Increasing choice of location – community and hospital settings, and individual or groups sessions of consultations
- Providing flexibility in the time of appointments and method of contact
- Target women from traditionally ‘hard to reach’ groups, in particular young people with diabetes and women from South Asian backgrounds from low socio-economic groups
- Reduce variation through a clearly defined clinical pathway as part of a care bundle.
3. Providing a safe service by
- Ensure all team members had the appropriate competencies as described by Skills for Health
- Compare the service with the previous Secondary Care consultant-led service
- Regular reviews of individual management plans, targets, and adverse events.
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